Midwifery is an old profession, but certainly not a redundant one. These medical professionals are responsible for not just one life, but two.

It takes dedication and passion to be a good midwife. Acting as a medical professional, cheerleader, and trusted advisor, a midwife must advocate for the best and safest birthing method for each one of their patients. Yet, some argue their importance in the health sector is overlooked and the profession is often neglected.

Being part of a miracle

“Many people haven’t a clue what the role of a midwife is,” says Louette Maccallum, a midwife with an estimated 5 000 births under her belt.

She describes the profession she has immersed herself in for the last 34 years with a sense of reverence. “I get to be part of a miracle with every birth I attend. To be able to assist women in their most vulnerable moments… and then to observe the transition from woman to mother and man to father and the joy in the moment of bringing their child into the world is the most beautiful thing to behold. 

“You need to be passionate, caring, compassionate, patient, and be willing to work day or night or both sometimes, with long hours and lots of physical work,” Maccallum says. Regardless of whether they have to conduct their duties in the cheerful daylight hours or in the muted darker hours, midwives play a vital part in the healthcare system. “Midwifery, where care includes proven interventions for maternal and newborn health as well as for family planning could avert over 80% of all maternal deaths, stillbirths and neonatal deaths,” the World Health Organisation (WHO) states in their 2020 campaign to honour nurses and midwives.

The core of maternal health

“Midwifery is the core of maternal health. If you strengthen midwifery in your country, then you are going to see healthy future generations,” says Dr Margreet Wibbelink, a midwife and current general manager at the organisation Sensitive Midwifery.

Midwives have these skills because they have been medically trained to monitor pregnant women and their babies through the entire duration of the pregnancy. According to Wibbelink, midwives are expected to care for expectant mothers from the start. 

“For the first visit, you will do the full examination, and ask all the (necessary) questions about the woman’s health, her medical history, and menstruation,” she says. “You are already screening her to see whether she is a low-risk (pregnancy) or if there are any red flags.” 

They will also conduct the necessary blood tests and confirm how far along the pregnancy is. From this first visit, the midwife begins a journey with the expectant mother. In the public health sector, this journey is likely to take place in a Midwife Obstetric Unit. “During the pregnancy they have regular consultation visits, where you do the blood pressure check, check the growth of the baby, check if the mom is well nourished, and her iron levels are fine,” Wibbelink says. 

“Because there is so much change (happening) in their bodies, they often have lots of questions,” she says. “You will answer them, and in that process, you are making them ready and empowering them for what’s ahead.” According to Colleen Frost, a former midwife, one of the best parts of the job was the relationships she built with patients. “They would then open up about many things. I’m not a counsellor, but I’m able to listen and to be empathetic towards them,” she says.

Power struggles

Midwives also work closely with obstetricians according to Wibbelink, and in the case of a complication or a high-risk pregnancy the doctor will be able to step in and perform a Caesarean-section. However, she cautions that in the private sector, there is currently a power struggle between obstetricians and midwives. 

“The doctors do all the antenatal check-ups, and the birth. The midwives monitor the women but under the doctor’s guidance. They are not independent practitioners. They have given massive territory to the doctors, who are ruling the whole pregnancy sphere,” Wibbelink says. 

Maccallum, who is currently working as an independent midwife, has seen this struggle too. “In the private hospital sector midwives have become carers and assistants. They are not operating in their full capacity. They look after women in labour and monitor the progress but no longer do hands-on births,” she says.

‘Old-fashioned’ vs. ‘modern’ medicine

According to Wibbelink this power struggle comes down to the notion that natural birth is old-fashioned and unnecessary, while modern medicine gives a safer and more convenient alternative in the form of interventions like Caesarean-sections and inducing labour. By extension, midwives could be seen as old-fashioned as well. However, anyone entertaining this notion will quickly be set straight by Wibbelink. “It’s not an old-fashioned thing,” she says emphatically. 

According to Wibbelink, the drive towards medicalisation and interventions is slowly being tempered by the realisation “that all these shiny interventions are not good for us”. As recently pointed out on the website AfricaCheck, the WHO previously recommended that caesarean rates should range between 10 and 15% but this recommendation was revised in 2014. Currently the WHO does not recommend an ideal caesarean section rate.

In comparison, South Africa’s rate of caesarean-sections seems relatively high.

According to the District Health Barometer 2015/2016, the national average for Caesarean-sections in the public sector was 26.2%. Rates appear to be even higher in the private sector. A 2012 study published in the British Journal of Midwifery, that focused on delivery methods used in the South African private sector, estimates that the rate is as high as 70%. While a more recent number from a single medical aid scheme, Discovery Health, indicates that the C-section rate among scheme members had risen to 74%, according to The Business Insider.

These high rates do not come without consequences, according to Wibbelink. She says that unnecessary interventions can cause set-backs for the newborn, as some babies are born slightly prematurely, as well as difficulties with bonding between mother and child, breastfeeding and a longer recovery time. According to the WHO report: “Caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons…

At population level, Caesarean section rates higher than 10% are not associated with reductions in maternal and newborn mortality rates,” the report states. The report further cautions that more research is needed into the exact effect that high C-section rates can have on health, and states that this method of delivery can cause complications. However, it does not specify the exact nature of these complications.

Journey to becoming a midwife

In order to become a midwife in South Africa, a person will need to undergo at least four years of training, according to a 2017 case study by the African Institute of Health & Leadership Development, regarding nursing and midwifery in South Africa. Midwives who were educated in South Africa, like Maccallum, are required to train to become registered nurses first, normally a three-year course, and then study for another year to get a second qualification in midwifery.

While some institutions, according to the case study, teach midwifery as part of a four year nursing degree, Maccallum started out as a general nurse in Neurology at Groote Schuur Hospital in Cape Town. Four years later she started her studies in midwifery at the B.G. Alexander College in Johannesburg. There, she fell in love with midwifery. “I just loved it so much and became so passionate about it that I stayed in midwifery since,” she says. 

According to Senior Manager for Education and Training at the South African Nursing Council (SANC), SJ Nxumalo, the reason South Africa’s path to midwifery is different to that of some other countries like the Netherlands which have a direct qualification for midwifery, is due to the demands of the public health sector.

“A nurse who is allocated in rural areas must be competent in providing comprehensive nursing, including midwifery services, in order to deal with the different needs of patients,” she explains. She adds that “each individual nurse must be comprehensively trained in order to deal with the quadruple burden of disease (that comes with midwifery)”. 

In order to qualify as a midwife, an individual is expected to complete 1 000 clinical hours, according to Nxumalo. She further explains that during this time students will be expected to spend 60 of those hours in an antenatal clinic or department. They will also be expected to work with at least 30 pregnant women, who they will examine under supervision. The aspiring midwives will then witness five births before they are allowed to deliver any babies themselves. 

The first birth

Frost, who obtained her qualification in 2001, still remembers the first birth she witnessed. “I remember that very well,” she laughs when asked to recall this experience.

“You don’t expect to smell those smells or see that amount of blood. Everyone thinks that it is like what you see on the television.” Frost pauses. “It’s definitely not like that. I remember feeling so dizzy,” she adds. “The smells and everything were completely foreign. I wanted to faint!” Once the student midwives have got through the required five births, they start the practical aspect of their training. For this, according to Nxumalo, they need to deliver 15 babies and do 15 internal examinations.

According to Nxumalo, student midwives during this time are also taught “breathing and relaxation techniques, antenatal exercises, post-natal exercises and performing episiotomies” (an incision made in the opening of the vagina during a difficult delivery). She further adds that once qualified the student will be able to “suture or stitch first and second-degree tears of the perineum and of episiotomies and administer local anaesthetic”. Nxumalo says depending on where they are working, a midwife can be expected to fulfil the duties of both nurse and midwife. 

Is the training sufficient?

Although 1 000 clinical hours and 15 deliveries may seem like a lot, Wibbelink doesn’t think that this is sufficient to train midwives properly. “International standard says you need to have done at least 40 births,” she says. 

Wibbelink has been conducting research for her PhD about the perceptions of midwives in the public sector. Within this research she claims to have encountered a similar concern among these midwives who state that “the new midwives are not skilled, not competent and lack practical training”. In addition, they also have to cope with the challenges in the public health sector. “There is a massive shortage of staff, and a lack of motivated midwives… There are things like the lack of resources, especially in rural areas. They battle with bad roads, ambulances that come too late, blood products that are not arriving. They’ve really got the worst end (of the bargain). Moms are dying unnecessarily under their hands.”

Very traumatising

Losing a patient, whether it is the mother or the baby, can haunt a midwife long after the death occurred. According to Frost, the patients that she remembers most are the ones who lost their babies. “I can still see some of their faces,” she says lowering her voice. “When they lose their babies in the form of a stillbirth, they still have to go through the normal birth process. There’s no joy in that. That I remember quite vividly.” Frost explains: “We then have to wrap that (stillborn) baby for the undertaker to collect the body… It’s very traumatizing.” 

According to Maccallum, conditions in the public health sector are horrific, and have led to traumatised and drained midwives. “These midwives are exhausted and in need of emotional support themselves. They are heroes,” she adds.

This article was produced by Spotlight – health journalism in the public interest.

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Elri Voigt